2025 Neola Try It

Return completed, signed form with the following items to your local church if Disciples or Missouri Union Presbytery All others, send items to CCMA Registrar PO Box 774 Mexico, Mo 65265 1) Copy of front and back of insurance card 2) Payment of fee - make check out to your local church

Please complete one form for each family unit

First and Last Name

Adult (over 18)Child

Child Age

MaleFemale

Last Tetanus

First and Last Name

Adult (over 18)Child

Child's Age

MaleFemale

Last Tetanus

First and Last Name

Adult (over 18)Child

Child's Age

MaleFemale

Last Tetanus

First and Last Name

Adult (over 18)Child

Child's Age

MaleFemale

Last Tetanus

First and Last Name

Adult (over 18)Child

Child's Age

MaleFemale

Last Tetanus

First and Last Name

Child's Age

MaleFemale

Last Tetanus

Address

Phone

City

State

Zip

Email Address

example@example.com

Best Method of Contact

EmailPhoneUS Mail

Special Requests For example We want to share a cabin with name family

We will do our best to honor special requests. They will be fulfilled in the order received.

Camp T-shirts (1/person. Put Number need in each box

Youth S

Youth M

Adult S

Adult M

Adult L

Adult XL

Adult XXL

Adult XXXL

Housing Options for Try-It Camp Prices are for 1 adult /1 child combination in cabin, with an option for either one extra single adult or extra child. For one adult/child pair, write "1" in the appropriate box (lodge or cabin For singles, write the number of individual extras on the appropriate line (lodge or cabin For example, for a family of four (2 adults and 2 youth) "2" in the $225 box. Total = $450. For a family of three (1 adult/child pair + 1 child write "1" in the $225 box and "1" in the Add'l Adult $65 (or Add'l Child $65) box. Total = $290. Questions?? Email zanew78@gmail.com or call 1-660-998-4158.

Number of Adult and Child Pairs ($235/pair)

Number of Additional Adults ($65/ addtional Adult)

Number of Additional Childern ($65/ addtional Child)

Total

* Fee includes housing, meals and all program expenses for Friday dinner-Sunday breakfast.

Releases and Authorizations: please sign and initial as directed

This Registration & Health History is correct and complete as far as I know. The person herein named as "camper" has permission to engage in all camp activities except as noted. I hereby give permission to the camp to provide, seek, and consent to routine health or dental care, administration of prescribed medication, and emergency treatment for me/my child, as may be deemed necessary, including but not limited to x-rays, routine tests, and treatment, and/or hospitalization.I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. It is my intention that the camp be treated as acting in loco parentis if the person herein named is a minor. Further it is my intention that the appropriate representatives of the camp be treated as "personal representatives" for the purposes of disclosing protected health information pursuant to the Health Insurance Portability and Accountability act of 1996. I hereby agree (pursuant to 45CFR$164.510(b to the disclosure to camp representatives of the protected health information of the person herein described, as necessary; (1) to provide relevant information to the camp representatives related to the person's ability to participate in camp activities; and (2) in the case of minors, relevant information to the camp representatives to keep me informed of my child's health status. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for trips out of camp. Please initial Transportation, Photography, and Medication Releases:

Wel give permission for ourmy child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by NEOLA camps of the Mid America Region (NEOLA) or Missouri Union Presbytery (MUP). Initials or write "NO"

Wel give permission for ourmy child to be photographed video or audio taped and understand that these photos videos or recordings may be used inNEOLA camps of the Mid America Region (NEOLA) or Missouri Union Presbytery (MUP) newsletters promotion or other print digital or internet publications. Initials or write "NO"

I authorize camp staff to administer overthecounter medication to my child for minor pain headache upset stomach sore throat cold symptoms or allergy. Initials or write "NO"

Signature of Custodial ParentGuardian or Adult CamperStaff

Date

Printed Name

Participant's Covenant As a family, we covenant with our Creator, the camp staff, and other campers to do our best while at camp to: Expect the best of others, and give our best in our activities together. Respect each person's dignity, affirming that each one is created VERY GOOD, in the image of God. Participate fully in activities and attend the entire camp session. Be a good steward of creation, appreciating and caring for the environment at camp. Abide by the camp rules, policies, and expectations. Grow in our relationship with Jesus Christ, through prayer, Bible study, worship and fellowship. Expect to make new friends, be a friend to others, and have fun. Create a community of hospitality and inclusion that honors the unique contributions of each person. Respect camp property and the property of other campers and staff.

Family Representatives Signature

Date

Health History (complete one for each individual)

Camper Name

Date of Last Physical Exam

Date

Insurance Information: Is the participant covered by medical /hospital insurance?

YesNo

If so list carrier or plan name

PolicyGroup

Physician

Physician Phone Number

Please enter a valid phone number.

DentistOrthodontist

DentistOrthodontist Phone Number

Please enter a valid phone number.

ALLERGIES List all known include medicines food insect stings or bites hay fever asthma animal etc

Describe reaction and management of reaction if more space is needed please attach an additional sheet

Diet and Nutrition

Regular DietRegular Vegetarian DietRequires Special Food Needs

Please Describe and special Food Needs

MEDICATIONS BEING TAKEN ATCAMP (including vitamins and over-the-counter or non-prescription drugs)

If you are staying in lodging with just your family, you may keep and administer medications yourself. If you are sharing lodging with adults or children other than your own family, medication must be checked in to the camp medic/nurse and will be administered by camp medical staff. All medication must be in the original package that identifies the patient, prescribing physician (if prescription drug), name of the medicine, dosage and frequency of administration.

GENERAL HEALTH: Check YES or NO for each statement. Please explain YES answers below, noting the number of the question. For travel outside country, please name countries visited. Has or does the camper:

	Yes	No
1. Had a recent injury, illness or infectious disease?
2. Have a chronic or recurring illness/condition?
3. Ever been hospitalized
4.Ever had surgery?
5. Headaches
6.Ever had a head injury?
7. fainting or dizziness
8.Ever had seizures or convulsions?
9. Ever passed out/had chest pain during or after exercise?
10. Have diabetes?
11. Have asthma/wheezing/shortness of breath?
12. Ever had back/joint problems?
13. Have any skin problems (e.g. itching, rash, acne)?
14. Had mononucleosis ("mono") in the past 12 months?
15. Had problems with diarrhea/constipation?
16. Have problems with falling asleep/sleepwalking?
17. If female, have problems with periods/menstruation?
18. Have a history of bedwetting?
19. Wear glasses, contacts, or protective eyewear?
20. Traveled outside the country in the past 9 months?

Please Explain any "Yes" answers. Please include the number of the question. if traveled outside of the country, list countries.

MENTAL, EMOTIONAL AND SOCIAL HEALTHCheck YES or NO for each statement. Please explain YES answers below, noting the number of the question, attach an additional sheet or write on back of this form if more space is needed. Has the camper:

	Yes	No
1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)?
2. Ever been treated for emotional or behavioral difficulties or an eating disorder?
3. During the past 12 months, seen a professional to address mental/emotional health concerns?
4.Had a significant life event that affects the camper? (abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, etc
5. Had a loved one serving in the military (currently or in the recent past)?

Please Explain any "Yes" answers. Please include the number of the question

What have we forgotten to ask Use this space to provide any additional information about the campers health or behavior that you think important or that may affect the campers ability to participate fully in the camp program If more space is needed please attach an additional sheet